From the Guidelines
Valve replacement, either through surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR), is the definitive treatment for severe symptomatic aortic stenosis. The choice between SAVR and TAVR depends on the patient's surgical risk, with TAVR being a viable alternative to SAVR irrespective of surgical risk, as demonstrated by recent randomized clinical trials 1.
Treatment Options
- SAVR involves open-heart surgery to replace the valve with a mechanical or biological prosthesis and is recommended for symptomatic severe AS, severe AS undergoing CABG, aortic surgery or other valve surgery, and asymptomatic severe AS with certain high-risk features 1.
- TAVR is a less invasive procedure, delivering a new valve via catheter, and is recommended for patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have aortic and vascular anatomy suitable for TAVR and a predicted survival of 12 months, and who have a prohibitive surgical risk or are at high surgical risk 1.
- Medical therapy cannot reverse stenosis but may help manage symptoms, including diuretics for fluid overload, avoiding vasodilators that can cause hypotension, and treating concurrent conditions like hypertension or atrial fibrillation 1.
- Balloon valvuloplasty is rarely used as a bridge therapy for patients with AS in whom surgical AVR cannot be performed because of serious comorbid conditions 1.
Monitoring and Follow-up
Patients should undergo regular follow-up with echocardiography and exercise testing to monitor disease progression, as early intervention is crucial in severe symptomatic aortic stenosis, with mortality rates of approximately 50% within two years of symptom onset. Asymptomatic patients with mild to moderate stenosis can be managed with watchful waiting and regular echocardiographic monitoring every 1-2 years.
From the Research
Treatment Options for Aortic Stenosis
- Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography 2
- Transcatheter aortic valve replacement (TAVR) has become the preferred treatment option in appropriate patients with symptomatic severe aortic stenosis (AS) 3
- Surgical valve replacement is the standard of care for patients at low to moderate surgical risk, while TAVR may be considered in patients at high or prohibitive surgical risk 2
Transcatheter Aortic Valve Replacement (TAVR)
- TAVR has emerged as a viable treatment option for patients with symptomatic aortic stenosis across all surgical risk groups 4
- TAVR is a feasible alternative for patients with symptomatic severe aortic stenosis and left ventricular dysfunction who are at high risk for surgical aortic valve replacement (SAVR) 5
- The transseptal approach has been described as a safe and effective approach for TAVR using the standard delivery system and under monitored anesthesia care (MAC) 4
Comparison of TAVR and SAVR
- Transcarotid TAVR (TC-TAVR) was associated with improved 30-day clinical outcomes compared with SAVR, with no significant differences in death, stroke, and hospitalization at 1-year follow-up 6
- TC-TAVR may be a valid alternative to SAVR in nontransfemoral-TAVR candidates 6
Patient Management
- Watchful waiting is recommended for most asymptomatic patients, with serial Doppler echocardiography every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease 2
- Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease will lead to optimal outcomes 2